Free Printable SBAR

Prepared by: [Your Name]

Date: August 27, 2050

Patient Name: Pearl Bergna
Date of Birth: March 14, 1975
Patient ID: 12345678

I. Situation

Current Issue:

Pearl Bergna has been admitted to the emergency department with severe abdominal pain, nausea, and vomiting. She reports a pain level of 8/10 on the pain scale. The pain began approximately 6 hours ago and has progressively worsened.

Vital Signs:

II. Background

Medical History:

• Chronic Conditions: Type 2 Diabetes Mellitus, Hypertension

• Previous Surgeries: Appendectomy (2010), Gallbladder Removal (2015)

• Medications: Metformin, Lisinopril

Recent Medical History:

• The patient had a similar episode of abdominal pain 3 months ago, which was resolved with conservative treatment.

Family History:

• Family history of gastrointestinal disorders and diabetes.

III. Assessment

Clinical Findings:

• Physical Examination: Possible rebound tenderness in the lower right abdomen.

• Laboratory Results: Awaiting blood results; initial tests show infection/inflammation.

• Imaging: Abdominal ultrasound shows potential signs of appendiceal inflammation.

Diagnosis Consideration:

• Possible acute appendicitis or other gastrointestinal issues.

IV. Recommendation

Proposed Actions:

1. Immediate Care: Initiate IV fluids and pain management.

2. Diagnostic Testing: Fast-track blood tests and confirm imaging (CT if needed).

3. Consultation: Refer to a surgical team for evaluation and intervention.

4. Monitoring: Continue to monitor vital signs and pain levels closely.

Follow-Up:

• Reassess the patient's condition in 1 hour or sooner if symptoms worsen.

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